New Client Inquiry Form

Please correct the errors described below.

We look forward to hearing from you. You will recieve a quicker and more efficient response when all applicable fields are filled out. All information provided is fully encrypted and HIPPA compliant. We will use this information to do a benefits check and determine available therapists based off the information provided and provider availibility.

IMPORTANT: Please provide an accurate phone number as this will be the way you will be contacted.

Name of person filling out this form

Name of potential client

Potential Client's Address

City

State

Zip

Phone

Email

The best way to reach me is:

By Phone

By Email

By Phone and Email

Potential Client's Date of Birth

How did you hear about us?

Name of Insurance Company

Member/Subscriber ID# (including alpha prefix if there is one)

Insurance Group #

Insurance contact phone # for providers (back of ins. card)

Customer service phone # (back of ins. card)

Provider One ID (for Medicaid plans only)

Optional: Secondary Insurance Information

What do you want to work on in therapy? You may list any current or previous mental health diagnosis.

Is there a particular type of treatment you are looking for?

Is there a particular type of service you are looking for? Check all that apply.

In-Person Appointments

Telehealth/Virtual Appointments

Evening and Weekend Appointments

Daytime Appointments

Family/Couples Therapy

Therapy from a Clinician of Color

Therapy from a LGBTQIA2S+ Ally

Therapy in Spanish Language

Preferred Provider (if known)

Is there anything else we need to know to better pair you with the right clinician?

Comments

Your information will be encrypted.

We look forward to hearing from you. You will recieve a quicker and more efficient response when all applicable fields are filled out. All information provided is fully encrypted and HIPPA compliant. We will use this information to do a benefits check and determine available therapists based off the information provided and provider availibility.

IMPORTANT: Please provide an accurate phone number as this will be the way you will be contacted.

Trauma Informed Therapies, PLLC

509-842-0067
traumainformedtherapies.com

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